Significant developments in the management of enterocutaneous fistulas have been made in the last decades, however, this pathology continues to represent a substantial problem to patients and their families, healthcare providers involved, and health systems. Once a fistula is diagnosed, preoperative patient optimization is paramount to achieve satisfactory outcomes. This should ideally be conducted by a multidisciplinary team and include strategies for limiting fluid and electrolyte losses, control of sepsis, definition of fistula anatomy, wound management, and aggressive nutrition interventions. Endoscopic treatments have emerged as adjuncts in the treatment of these gastrointestinal disturbances, sometimes with complete closure, and other times as a bridge towards the definitive surgical intervention. While a minority of fistulas will close spontaneously, most will require a definitive surgical intervention after a few months of patient optimization. The associated abdominal wall defect needs to be addressed at the time of fistula take-down. Single-stage repair involves restoration of bowel continuity and definitive hernia repair in the same setting. Due to the potential for complications, including re-fistulization, this is an acceptable option in specialized centers with expertise in both enterocutaneous fistula management and advanced abdominal wall reconstruction. Most patients benefit from a staged repair, in which the definitive hernia operation is undertaken a few months after fistula take-down. Strategies for closure of the abdominal wall at the time of fistula resection include primary fascial closure, dynamic fascial closure devices, use of resorbable meshes to bridge fascial defects, and the use of cutaneous or myocutaneous flaps.